Palpitations

Last updated 1 Jun 2026 · Cardiology

📋 Key Information Summary

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Palpitations are the subjective awareness of an irregular, forceful, or rapid heartbeat and account for approximately 16% of cardiology referrals in Australia.
The most common causes are premature ventricular/supraventricular ectopics, supraventricular tachycardia (SVT), and atrial fibrillation (AF); anxiety and non-cardiac causes account for up to 30% of presentations.
A structured diagnostic model combining history, ECG, Holter monitoring, and echocardiography identifies an arrhythmic cause in up to 75% of cases when applied systematically.
Red flags demanding urgent evaluation include syncope or presyncope during palpitations, haemodynamic compromise, family history of sudden cardiac death (age <40), and exercise-induced symptoms.
A 12-lead ECG during symptoms remains the single most valuable diagnostic test; if symptoms are infrequent, 24–72-hour Holter, event recorders, or implantable loop recorders should be considered.
SVT (most commonly AV nodal re-entrant tachycardia) presents with abrupt onset/offset regular tachycardia at 150–250 bpm; vagal manoeuvres or IV adenosine (6 mg → 12 mg) are first-line acute management.
Atrial fibrillation affects approximately 2.4% of Australians aged ≥25 years and is the most common sustained arrhythmia, with stroke risk stratified by CHA₂DS₂-VASc score.
Frequent ventricular ectopics (>10% burden on Holter) warrant echocardiography and may require treatment if associated with ventricular dysfunction.
Drug-induced palpitations are common — always review medications including sympathomimetics, QT-prolonging agents, caffeine, alcohol, and illicit substances.
The Vaughan-Williams antiarrhythmic classification (Classes I–IV) guides pharmacotherapy; Class IC agents (flecainide) are contraindicated in structural heart disease.
Rate control is first-line for AF (beta-blockers, diltiazem, digoxin); rhythm control (flecainide, amiodarone, catheter ablation) is reserved for symptomatic patients despite rate control.
Aboriginal and Torres Strait Islander Australians have higher rates of rheumatic heart disease, AF, and delayed presentation; culturally safe screening and rural access to ambulatory ECG monitoring are essential.
Always assess for haemodynamic instability (hypotension, altered consciousness, chest pain) — this mandates immediate synchronised cardioversion rather than pharmacotherapy.

Introduction & Australian Epidemiology

Palpitations are the subjective perception of an abnormal heartbeat, whether rapid, forceful, irregular, or a combination thereof. They are one of the most common presenting complaints in primary care and emergency departments across Australia, accounting for approximately 1 in 6 cardiology outpatient referrals. Although often benign, palpitations may herald a clinically significant arrhythmia that warrants prompt investigation and management.

The differential diagnosis is broad, spanning cardiac causes (arrhythmias, valvular disease, cardiomyopathy), systemic causes (thyrotoxicosis, anaemia, phaeochromocytoma), psychological causes (anxiety, panic disorder), and pharmacological causes (sympathomimetics, caffeine, alcohol, recreational drugs). A systematic diagnostic approach is therefore essential to distinguish benign from potentially life-threatening aetiologies.

Australian Epidemiology

Atrial fibrillation (AF): Prevalence of approximately 2.4% in Australians aged ≥25 years (NATIONAL AF prevalence study), with an estimated 300,000–400,000 affected individuals. AF prevalence rises sharply with age, affecting >10% of those aged ≥75 years.
SVT: Lifetime prevalence of approximately 2.25% in the general population. AVNRT is the most common mechanism in Australian practice, particularly in younger women.
Ventricular ectopics: Identified on Holter monitoring in up to 75% of the general population; clinically significant (burden >10%) in approximately 1–2%.
Emergency presentations: Palpitations account for approximately 0.8–1.1% of all emergency department presentations nationally, with the majority discharged after evaluation.
Aboriginal and Torres Strait Islander Australians: AF prevalence is estimated to be 1.5–2 times higher than in non-Indigenous Australians, compounded by higher rates of rheumatic heart disease, rheumatic fever, and comorbidities such as type 2 diabetes and chronic kidney disease.
The total economic burden of AF in Australia exceeds

.5 billion annually, including hospital admissions, stroke management, and loss of productivity.

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Key clinical principle: The majority of palpitations are caused by benign ectopic beats or SVT. However, a small but clinically important proportion represent potentially lethal arrhythmias (ventricular tachycardia, long QT-related torsades de pointes, Brugada syndrome). A thorough initial assessment is critical to avoid missed diagnoses.

Palpitations Diagnostic Model & Red Flags

Structured Diagnostic Approach

The evaluation of palpitations follows a stepwise model combining focused history, physical examination, baseline investigations, and ambulatory monitoring. Identifying the rhythm at the time of symptoms is the primary diagnostic goal.

Focused History

Onset (sudden vs gradual), offset, duration, frequency, regularity, associated symptoms (syncope, dyspnoea, chest pain), precipitants (posture, exertion, caffeine, alcohol, medications), and family history of sudden cardiac death.

Physical Examination

Cardiovascular examination including pulse character, rhythm, blood pressure in both arms, auscultation for murmurs (aortic stenosis, mitral valve prolapse), signs of thyrotoxicosis (tremor, goitre, exophthalmos), and signs of heart failure.

12-Lead ECG

Resting 12-lead ECG is mandatory for all patients. Look for WPW pattern (short PR, delta wave), QTc prolongation (>450 ms male, >470 ms female), Brugada pattern (ST elevation V1–V3), LVH, and ischaemic changes. A normal resting ECG does not exclude arrhythmia.

Ambulatory Monitoring

24-hour Holter for daily symptoms; 2–4-week event recorder or patch monitor for weekly symptoms; implantable loop recorder (ILR) for infrequent or unexplained syncope. Australian MBS item numbers apply for Holter (11707) and event monitoring (11710).

Further Investigations

Echocardiography if structural heart disease suspected; thyroid function tests (TSH, fT4); FBC for anaemia; serum electrolytes; electrophysiology study (EPS) for recurrent unexplained palpitations or suspected SVT/VT.

Red Flags — Features Demanding Urgent Evaluation

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Syncope or presyncope occurring during palpitations — suggests haemodynamically significant arrhythmia (VT, high-grade AV block)
Haemodynamic instability: systolic BP <90 mmHg, altered consciousness, diaphoresis, ongoing chest pain
Family history of sudden cardiac death at age <40 years (think hypertrophic cardiomyopathy, long QT syndrome, Brugada, ARVC)
Exercise-induced palpitations or syncope — may indicate catecholaminergic polymorphic VT (CPVT), HCM, or aortic stenosis
New-onset irregular pulse with heart failure signs — consider AF with rapid ventricular response
Known structural heart disease (post-MI, cardiomyopathy, valvular disease) — elevated risk of ventricular arrhythmia
ECG abnormalities: pre-excitation (WPW), prolonged QTc >500 ms, Brugada pattern, epsilon waves (ARVC)

History Features Suggesting Specific Aetiologies

Feature	Likely Diagnosis
Sudden onset/offset, regular rapid rate, terminated by vagal manoeuvres	SVT (AVNRT or AVRT)
Irregularly irregular rhythm, may be asymptomatic	Atrial fibrillation
"Skipped beat" or "flip-flopping" sensation, often at rest	Premature ectopics (PVC or PAC)
Associated with exertion, syncope, or family history of SCD	Ventricricular tachycardia, HCM, CPVT
Gradual onset/offset, regular, rate 100–150 bpm	Sinus tachycardia (anxiety, exercise, fever, thyrotoxicosis)
Worse when lying on left side, positional variation	Benign ectopics or anxiety-related palpitations
Polydipsia, weight loss, tremor, heat intolerance	Thyrotoxicosis

Types of Arrhythmias (SVT, AF, Ectopics)

Supraventricular Tachycardia (SVT)

SVT refers to any tachyarrhythmia originating above the ventricles, excluding atrial fibrillation and atrial flutter. The three principal mechanisms are AV nodal re-entrant tachycardia (AVNRT, ~60%), AV re-entrant tachycardia (AVRT, ~30%, including Wolff-Parkinson-White syndrome), and atrial tachycardia (~10%).

Typical Presentation

AVNRT

Abrupt onset/offset, regular tachycardia 150–250 bpm. Often described as a "racing" or "pounding" heart. Palpitations in the neck ("frog in throat") from cannon A waves is highly suggestive. Terminates with vagal manoeuvres.

Setting: ED or GP — vagal manoeuvres, adenosine

Pre-excited

AVRT / WPW

Similar presentation to AVNRT but ECG may show pre-excitation (delta wave, short PR) at baseline. Risk of rapid anterograde conduction via accessory pathway during AF — potentially life-threatening (VF risk). Avoid AV-nodal blocking agents in pre-excited AF.

Setting: Cardiology referral — risk stratification ± EPS

Ongoing

Refractory SVT

SVT unresponsive to vagal manoeuvres and adenosine. Consider IV verapamil, IV metoprolol, or synchronised cardioversion if haemodynamically compromised. Catheter ablation is curative in >95% of AVNRT and AVRT cases.

Setting: Cardiology — catheter ablation referral

Acute SVT Management

Vagal Manoeuvres

Valsalva (strain against closed glottis for 15–20 s), carotid sinus massage (one side only, avoid if carotid bruit), or face immersion in cold water (diving reflex). Modified Valsalva with passive leg elevation after strain has higher conversion rate (~43%).

Adenosine IV

6 mg rapid IV bolus via large-bore cannula, flush with 20 mL NS. If no effect after 1–2 minutes, give 12 mg. May repeat 12 mg once. Contraindicated in pre-excited AF. Warn patient of transient chest tightness and flushing.

IV Calcium Channel Blocker / Beta-Blocker

Verapamil 5–10 mg IV over 2–3 minutes (avoid in HFrEF), or metoprolol 5 mg IV (repeat up to 15 mg total). Avoid verapamil if adenosine not yet tried in uncertain diagnosis.

Synchronised Cardioversion

If haemodynamically unstable — sedation and synchronised DC cardioversion starting at 50 J (biphasic) for regular narrow-complex tachycardia.

Atrial Fibrillation (AF)

AF is the most common sustained cardiac arrhythmia in Australia. It is characterised by disorganised atrial electrical activity resulting in an irregularly irregular ventricular response. AF is classified as: first detected, paroxysmal (self-terminating, usually within 48 hours), persistent (sustained >7 days or requiring cardioversion), long-standing persistent (>12 months), and permanent (accepted by patient and clinician).

Stroke Risk Stratification — CHA₂DS₂-VASc Score

Risk Factor	Points
C — Congestive heart failure (or LVEF ≤40%)	1
H — Hypertension	1
A₂ — Age ≥75 years	2
D — Diabetes mellitus	1
S₂ — Stroke/TIA/thromboembolism history	2
V — Vascular disease (MI, PAD, aortic plaque)	1
A — Age 65–74 years	1
Sc — Sex category (female)	1

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Anticoagulation guidance: Oral anticoagulation (OAC) is recommended for all patients with CHA₂DS₂-VASc ≥2 (men) or ≥3 (women). Consider OAC for score 1 (men) or 2 (women) after shared decision-making. Direct oral anticoagulants (DOACs — apixaban, rivarelbano, edoxaban, dabigatran) are preferred over warfarin for non-valvular AF. Warfarin remains indicated for mechanical heart valves and moderate-to-severe mitral stenosis.

AF Management: Rate vs Rhythm Control

Rate Control (First-Line for Most)

Beta-blockers (metoprolol 25–100 mg BD PO, or atenolol 50–100 mg daily PO)
Diltiazem (diltiazem CD 180–360 mg daily PO) — avoid in HFrEF
Digoxin (loading 500 mcg PO BD × 2 days then 62.5–250 mcg daily; useful in heart failure and sedentary patients)
Target resting HR <110 bpm (lenient) or <80 bpm (strict) per guidelines

Rhythm Control (If Symptomatic Despite Rate Control)

Flecainide 100–200 mg BD PO (only if no structural heart disease — "pill in the pocket" for infrequent paroxysmal AF)
Amiodarone 200 mg TDS × 1 week → 200 mg BD × 1 week → 200 mg daily (maintenance); effective but significant long-term toxicity
Sotalol 80–160 mg BD PO (Class III activity; monitor QTc)
DC cardioversion (synchronised, biphasic 120–200 J) for AF <48 h or after TEE exclusion of LA thrombus
Catheter ablation (pulmonary vein isolation) — superior to drugs for maintaining sinus rhythm, particularly in paroxysmal AF

Premature Ectopic Beats

Premature atrial contractions (PACs) and premature ventricular contractions (PVCs) are the most common cause of palpitations in clinical practice. They are frequently benign but may indicate underlying structural heart disease when frequent or complex.

Feature	PACs	PVCs
ECG appearance	Narrow complex, premature P wave (may be buried), followed by normal or aberrant QRS	Wide complex (>120 ms), no preceding P wave, compensatory pause
Symptoms	"Fluttering," "skipped beat"	"Thump in chest," compensatory pause perceived as missed beat
Clinical significance	Usually benign; frequent PACs (>30/hour) associated with AF risk	Usually benign; burden >10% may cause PVC-induced cardiomyopathy
Investigation threshold	ECG, TSH; Holter if frequent or symptomatic	ECG, echo if burden >10% or symptoms are severe
Treatment	Reassurance; beta-blocker if highly symptomatic	Reassurance; beta-blocker or flecainide; catheter ablation for refractory PVC-induced cardiomyopathy

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PVC-induced cardiomyopathy: A PVC burden >15–20% on 24-hour Holter is associated with progressive left ventricular dysfunction, even in the absence of structural heart disease. Early recognition and treatment (catheter ablation or antiarrhythmic drug) can reverse ventricular impairment. Echocardiography is mandatory in all patients with high PVC burden.

Drug Causes of Palpitations

A thorough medication history is an essential component of evaluating palpitations. Numerous prescription, over-the-counter, and illicit substances can provoke or exacerbate arrhythmias through sympathomimetic effects, QT prolongation, electrolyte disturbance, or direct myocardial toxicity.

Common Drug and Substance Causes

Category	Examples	Mechanism	Clinical Effect
Sympathomimetics	Salbutamol (high-dose nebulised), adrenaline, pseudoephedrine, phenylephrine, methylphenidate, amphetamines	β₁-receptor stimulation → ↑ HR, ↑ automaticity	Sinus tachycardia, PACs, PVCs, SVT, VT
QT-Prolonging Drugs	Ondansetron, haloperidol, citalopram, escitalopram, methadone, erythromycin, clarithromycin, fluconazole, domperidone, sotalol	Blockade of IKr (hERG) potassium channels → prolonged repolarisation	Torsades de pointes (polymorphic VT), syncope, sudden cardiac arrest
Stimulants & Recreational	Caffeine (high-dose), cocaine, MDMA (ecstasy), methamphetamine, synthetic cannabinoids, energy drinks	Sympathomimetic + sodium channel effects (cocaine); catecholamine surge	Sinus tachycardia, AF, VT, VF, coronary vasospasm
Antidepressants	TCAs (amitriptyline), venlafaxine, lithium toxicity	Sodium channel blockade (TCAs), sympathomimetic (venlafaxine)	Sinus tachycardia, QRS widening, VT, QT prolongation
Antiarrhythmic Drugs	Digoxin toxicity, flecainide overdose, amiodarone	Proarrhythmic effect, especially in structural heart disease or toxicity	Bidirectional VT (digoxin), incessant VT (flecainide), QT prolongation (amiodarone)
Alcohol	Binge drinking ("holiday heart syndrome"), chronic excess	Direct atrial toxicity, autonomic effects, electrolyte depletion	Paroxysmal AF (holiday heart), SVT, PVCs
Herbal & Supplements	Ma huang (ephedra), ginseng (high-dose), bitter orange (synephrine), licorice (hypokalaemia)	Sympathomimetic, electrolyte disturbance	Sinus tachycardia, PVCs, AF

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QTc monitoring: When prescribing QT-prolonging drugs, check baseline ECG (QTc) and repeat after reaching steady state. Risk is amplified by hypokalaemia, hypomagnesaemia, bradycardia, female sex, congenital long QT syndrome, and concomitant use of ≥2 QT-prolonging agents. Discontinue or substitute if QTc exceeds 500 ms or increases >60 ms from baseline.

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Cocaine-associated chest pain and arrhythmia: Avoid beta-blockers (including metoprolol) in acute cocaine toxicity — unopposed alpha-stimulation may worsen coronary vachycardia and hypertension. Use benzodiazepines (diazepam 5–10 mg IV) as first-line. If rate control needed, consider diltiazem. Sodium bicarbonate for QRS widening due to cocaine sodium channel blockade.

Drug-Induced Torsades de Pointes — Risk Reduction

Correct electrolytes: maintain K⁺ ≥4.0 mmol/L and Mg²⁺ ≥0.8 mmol/L
Avoid combining ≥2 QT-prolonging agents
Dose-adjust for renal and hepatic impairment
Obtain ECG at baseline, 1 week after initiation, and after dose changes
Immediate treatment of TdP: IV magnesium sulfate 2 g over 5–10 minutes (first-line); isoprenaline or temporary pacing if recurrent; defibrillation if haemodynamically unstable

Antiarrhythmic Drug Classification

The Vaughan-Williams classification categorises antiarrhythmic drugs by their primary mechanism of action. While widely used, it is an oversimplification — many agents have mixed properties (e.g., amiodarone has Class I, II, III, and IV activity). Nevertheless, it remains the standard framework in Australian clinical practice and training.

Vaughan-Williams Classification Overview

Class	Mechanism	Key Agents	Primary Indications	Major Risks
IA	Na⁺ channel blockade (intermediate binding kinetics); prolong repolarisation	Quinidine, procainamide, disopyramide	AF/Flutter (rarely used in Australia now), VT	QT prolongation, TdP (IA); negative inotropy (disopyramide); lupus-like syndrome (procainamide)
IB	Na⁺ channel blockade (fast binding kinetics); shorten repolarisation	Lidocaine (lignocaine), mexiletine	VT (lidocaine — IV, acute setting); mexiletine (oral, for ventricular arrhythmias)	CNS toxicity at high levels (confusion, seizures); bradycardia; mexiletine — nausea
IC	Na⁺ channel blockade (slow binding kinetics); markedly slow conduction	Flecainide, propafenone	SVT, paroxysmal AF (rhythm control), WPW	CONTRAINDICATED in structural heart disease (CAST trial — increased mortality post-MI); proarrhythmia in ischaemic cardiomyopathy
II	Beta-adrenergic receptor blockade	Metoprolol, atenolol, bisoprolol, carvedilol, esmolol (IV), propranolol	Rate control (AF, SVT, sinus tachycardia); post-MI VT prevention; HCM	Bradycardia, bronchospasm, fatigue, hypotension; contraindicated in severe asthma; avoid in cocaine toxicity
III	K⁺ channel blockade → prolonged repolarisation and refractoriness	Amiodarone, sotalol, dronedarone, dofetilide	AF (amiodarone, sotalol, dronedarone); VT/VF (amiodarone — first-line ACLS)	QT prolongation/TdP (sotalol, dofetilide); amiodarone — thyroid, pulmonary fibrosis, hepatotoxicity, corneal deposits, photosensitivity, peripheral neuropathy
IV	L-type calcium channel blockade	Verapamil, diltiazem	Rate control AF/SVT; SVT termination IV	Negative inotropy (avoid in HFrEF); bradycardia; hypotension; constipation (verapamil); do not combine with beta-blockers acutely IV
Other	Mixed mechanisms	Digoxin (vagotonic, AV node blockade), adenosine (A₁ receptor agonist → transient AV block), ivabradine (If channel), magnesium (membrane stabiliser)	Digoxin: AF rate control in heart failure; Adenosine: acute SVT diagnosis/termination; Magnesium: TdP	Digoxin toxicity (narrow therapeutic index, monitor levels); adenosine — transient asystole, bronchospasm

Key Antiarrhythmic Drugs — Australian Clinical Detail

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Flecainide

Tambocor® · Class IC

Adult dose 50–200 mg PO BD (start 50 mg BD, titrate)

Key indication Paroxysmal AF (rhythm control), SVT, "pill-in-the-pocket"

Contraindication Structural heart disease, IHD, HFrEF, Brugada syndrome

Renal adjustment Reduce dose if eGFR <35 mL/min; monitor levels

PBS status ✔ PBS General Benefit

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Amiodarone

Aratac® · Cordarone X® · Class III (multiclass)

Adult dose (PO) 200 mg TDS × 1 week → 200 mg BD × 1 week → 100–200 mg daily maintenance

Adult dose (IV) 300 mg IV over 20–120 min (in 250 mL 5% dextrose), then 900 mg over 24 h

Key indication AF (rhythm control), VT/VF (ACLS first-line), SVT refractory

Monitoring TFTs, LFTs, CXR, ECG every 6 months; ophthalmology annually

Renal adjustment None required (hepatically metabolised)

PBS status ✔ PBS General Benefit

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Sotalol

Sotacor® · Class III / Class II

Adult dose 80–160 mg PO BD (start 80 mg BD)

Key indication AF (rhythm control), VT prevention

Key risk QT prolongation → TdP; monitor QTc; avoid if QTc >450 ms

Renal adjustment Dose interval extended to TDS/QID if eGFR 30–60; avoid if eGFR <10

PBS status ✔ PBS General Benefit

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Adenosine

Adenocor® · Not classified (A₁ receptor agonist)

Adult dose 6 mg rapid IV push → 12 mg if no effect (may repeat 12 mg once)

Key indication Acute SVT termination; diagnostic (unmask atrial flutter / AF)

Cautions Avoid in pre-excited AF; reduce dose to 3 mg if via central line or with dipyridamole/carbamazepine; avoid in severe asthma

Renal adjustment None (t½ 6 seconds)

PBS status ✔ PBS General Benefit (hospital)

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Metoprolol

Betaloc® · Lopresor® · Class II (beta-blocker)

Adult dose (PO) 25–200 mg PO daily or BD (rate control: start 25–50 mg BD)

Adult dose (IV) 5 mg IV over 2 min, repeat up to 15 mg total

Key indication AF rate control, SVT, sinus tachycardia, post-MI

Renal adjustment None required (hepatically metabolised)

PBS status ✔ PBS General Benefit

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Verapamil

Isoptin® · Cardilopin® · Class IV (CCB)

Adult dose (PO) Diltiazem CD 180–360 mg daily (preferred for AF); Verapamil SR 120–480 mg daily

Adult dose (IV) Verapamil 5–10 mg IV over 2–3 min

Key indication AF rate control (without HFrEF), SVT acute and maintenance

Key risk Negative inotropy — AVOID in HFrEF; do not combine IV with IV beta-blockers

PBS status ✔ PBS General Benefit

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Digoxin

Digitek® · Lanoxin® · Other (cardiac glycoside)

Adult dose Loading: 500 mcg PO BD × 2 days (or 750–1000 mcg IV stat) → maintenance 62.5–250 mcg daily PO

Key indication AF rate control in heart failure; adjunct for HFrEF with ongoing symptoms

Key risk Narrow therapeutic index — toxicity risk with hypokalaemia, renal impairment, amiodarone. Therapeutic range: 0.5–2.0 mcg/L

Renal adjustment Dose reduce by 50% if eGFR <30; monitor levels

PBS status ✔ PBS General Benefit

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Dronedarone

Multaq® · Class III (multiclass)

Adult dose 400 mg PO BD (with food)

Key indication AF (rhythm + rate control); alternative to amiodarone with better toxicity profile

Contraindication Permanent AF (ANDROMEDA trial — increased mortality in severe HF); NYHA Class III–IV HF

Renal adjustment None required

PBS status ⚑ Authority Required

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Safety-critical rule — Class IC agents (flecainide, propafenone): These are absolutely contraindicated in patients with structural heart disease (ischaemic heart disease, cardiomyopathy, significant LVH) based on the CAST trial, which demonstrated increased mortality. Echocardiography must be performed before initiation. They should only be prescribed in combination with an AV-nodal blocking agent when used for AF.

Investigations

Investigation selection depends on the frequency and severity of symptoms, clinical suspicion, and red-flag features. The primary goal is to capture the cardiac rhythm during symptoms.

Essential

12-Lead ECG

First-line for all patients. Looks for WPW (delta wave), prolonged QTc, Brugada pattern, LVH, ischaemic changes, atrial flutter waves, AV block. Normal ECG does not exclude arrhythmia.

Available

24–72-Hour Holter Monitor

MBS item 11707. For daily or near-daily symptoms. Correlate symptoms with rhythm diary. Sensitivity ~50% if symptoms are infrequent.

Available

Event Recorder / Patch Monitor (2–4 weeks)

MBS item 11710. Zio Patch, King of Hearts, CardiacSense. For weekly symptoms. Patient-activated or auto-trigger. Diagnostic yield ~75–90%.

Referral

Implantable Loop Recorder (ILR)

Subcutaneous device (e.g., Medtronic Reveal LINQ). Up to 3 years continuous monitoring. For infrequent unexplained syncope/palpitations. Requires procedural insertion (GP referral to cardiology).

Available

Transthoracic Echocardiography

MBS item 55118. Indicated if structural heart disease suspected, high PVC burden (>10%), new AF, heart failure signs, or murmur on examination. Assesses LVEF, valvular function, LA size.

Available

Blood Tests

TSH (thyrotoxicosis), FBC (anaemia), UEC (electrolytes — K⁺, Mg²⁺, Ca²⁺), BNP/NT-proBNP (if heart failure suspected), fasting glucose/HbA1c, serum iron studies if indicated.

Specialist

Electrophysiology Study (EPS)

Indicated for recurrent SVT (pre-ablation mapping), suspected VT, unexplained syncope with structural heart disease, risk stratification in WPW (accessory pathway refractory period). Performed by electrophysiologist in cardiac catheterisation lab.

Specialist

Cardiac MRI

For suspected ARVC, HCM with equivocal echo, cardiac sarcoidosis, or myocarditis. Late gadolinium enhancement identifies fibrosis.

Monitoring Strategy by Symptom Frequency

Continuous

Daily Symptoms

Resting ECG during symptoms if possible; 24-hour Holter monitor (MBS 11707).

Setting: GP

Weekly

Weekly to Monthly Symptoms

Extended ambulatory monitor — 2–4 week patch or event recorder (MBS 11710). Smartphone-based single-lead ECG (e.g., Apple Watch, KardiaMobile) may assist if medical-grade device unavailable.

Setting: GP ± Cardiology

Rare

Infrequent or Unexplained Symptoms / Syncope

Implantable loop recorder (cardiology referral). Consider EPS if structural heart disease present.

Setting: Cardiology / EP specialist

Special Populations

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Pregnancy

Common arrhythmias: SVT and PVCs are the most common; AF is rare but increasing with advanced maternal age.

Preferred rate/rhythm control: Metoprolol (PO/IV), flecainide, and sotalol are generally considered safe in pregnancy. Verapamil is acceptable if beta-blockers contraindicated. Avoid amiodarone (fetal thyroid toxicity, goitre) unless life-threatening arrhythmia.

Anticoagulation in AF: Warfarin is teratogenic in the first trimester (Category D). Use LMWH (enoxaparin 1 mg/kg BD SC) or adjusted-dose UFH. DOACs are not recommended in pregnancy.

DC cardioversion: Safe in all trimesters for haemodynamically significant arrhythmias.

Adenosine: Category B2 — can be used for acute SVT if vagal manoeuvres fail.

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Paediatrics

SVT is the most common significant arrhythmia in children. Presentation: irritability, poor feeding, tachycardia >220 bpm in infants.

Adenosine dose: 0.1 mg/kg rapid IV push (max first dose 6 mg); second dose 0.2 mg/kg (max 12 mg).

Long QT syndrome: Consider in any child with exercise-induced syncope or family history of sudden death. ECG screening recommended for all first-degree relatives.

Post-surgical AV block: Transient complete heart block may follow cardiac surgery (e.g., VSD repair). Permanent pacemaker required if persistent >7–14 days.

Referral: All paediatric arrhythmias should be managed in conjunction with a paediatric cardiologist.

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Elderly (≥65 years)

AF prevalence exceeds 10% in those aged ≥75 years. Higher stroke risk (CHA₂DS₂-VASc typically ≥3); anticoagulation is under-prescribed in this cohort.

Rate control: Digoxin useful in sedentary elderly patients with heart failure; beta-blockers preferred in those with preserved EF. Diltiazem — caution with concomitant beta-blockers.

Falls risk: Rate-controlling agents can cause orthostatic hypotension and bradycardia. Titrate slowly, monitor lying-standing BP.

Polypharmacy: Increased risk of drug interactions (amiodarone + warfarin → ↑ INR; digoxin + amiodarone → ↑ digoxin level). Use DOACs with dose adjustment for age/renal function.

DOAC dose adjustment: Apixaban 2.5 mg BD if ≥2 of: age ≥80, weight ≤60 kg, Cr ≥133 µmol/L. Rivaroxaban 15 mg daily if eGFR 15–49.

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Renal Impairment

Sotalol: Excreted renally — extend interval or reduce dose if eGFR <60; contraindicated if eGFR <10.

Digoxin: Narrow therapeutic index worsened by renal impairment. Reduce dose by 50% if eGFR <30. Monitor levels (target 0.5–2.0 mcg/L, ideally 0.5–0.9 mcg/L).

Metoprolol, amiodarone, dronedarone: No dose adjustment required (hepatically metabolised).

DOACs: Rivaroxaban 15 mg daily if eGFR 15–49; apixaban dose-adjusted as above; dabigatran avoid if eGFR <30; edoxaban 30 mg daily if eGFR 15–50.

Electrolytes: Hyperkalaemia and hypomagnesaemia are common in CKD and predispose to arrhythmias. Correct aggressively before initiating antiarrhythmics.

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Hepatic Impairment

Amiodarone: Hepatotoxicity risk increased. Monitor LFTs at baseline and every 6 months. Avoid in severe hepatic impairment (Child-Pugh C).

Flecainide, propafenone: Hepatically metabolised — accumulation in liver disease. Use with caution and reduce dose.

Metoprolol: Hepatically metabolised — bioavailability increases with liver disease. Start at lower dose. Consider atenolol (renally cleared) as alternative.

Warfarin: Increased sensitivity in hepatic impairment (reduced clotting factor synthesis). Lower starting dose, frequent INR monitoring.

DOACs: Contraindicated in Child-Pugh B/C (apixaban, rivaroxaban); dabigatran avoided in severe hepatic disease.

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Immunocompromised

Drug interactions: Amiodarone interacts with numerous immunosuppressants. Cyclosporine and tacrolimus levels may rise. Azole antifungals (fluconazole, voriconazole) inhibit CYP3A4 → ↑ levels of amiodarone, dronedarone, and some calcium channel blockers.

Infection-related palpitations: Febrile illness, sepsis, and myocarditis can all trigger arrhythmias. CMV and EBV myocarditis should be considered in transplant recipients with new arrhythmia.

QT prolongation: Many anti-infective agents prolong QTc (erythromycin, fluconazole, haloperidol, methadone). Risk is compounded in immunosuppressed patients on multiple medications.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Higher Burden of AF

Aboriginal and Torres Strait Islander Australians have AF rates estimated at 1.5–2 times that of non-Indigenous Australians. This is compounded by higher prevalence of rheumatic heart disease (RHD), type 2 diabetes, chronic kidney disease, obesity, and smoking — all of which are independent AF risk factors. AF often presents earlier and is more likely to be associated with valvular heart disease (particularly RHD-related mitral stenosis).

Rheumatic Heart Disease

RHD remains endemic in many Aboriginal and Torres Strait Islander communities, particularly in the Northern Territory, northern Queensland, and northern Western Australia. RHD-related mitral stenosis is a major cause of AF in this population and requires anticoagulation with warfarin (not DOACs) per current guidelines. Regular penicillin prophylaxis and echocardiographic surveillance are essential.

Access to Ambulatory Monitoring

Remote and very remote communities often lack access to Holter monitoring, event recorders, and echocardiography. Telehealth and point-of-care ECG devices (single-lead and 12-lead portable devices) can be used with remote cardiologist interpretation. NT Cardiac, RHDAustralia, and state-based RHD programs can facilitate equipment provision and specialist outreach clinics.

Cultural Safety

Assessments should be conducted in culturally safe environments. Avoid the term "palpitations" alone — explain in plain language ("feeling your heart beating fast or irregularly"). Engage Aboriginal Health Workers and Aboriginal Community Controlled Health Organisations (ACCHOs) in education, screening, and chronic disease management. Yarning-based approaches improve engagement and trust.

Medication Adherence & Access

Remote communities may face challenges accessing medications (especially DOACs and specialist antiarrhythmics). Closest pharmacy may be hundreds of kilometres away. Medication adherence programs (e.g., Patient-Assisted Transport Scheme, Remote Area Aboriginal Health Services) are essential. Long-acting depot formulations and blister packs may improve adherence. PBS Remote Area Aboriginal Health Services supplies can be utilised.

Stroke Prevention

AF-related stroke burden is disproportionately high. Ensure all Aboriginal and Torres Strait Islander patients with AF are assessed for anticoagulation (CHA₂DS₂-VASc). Warfarin is required for RHD-related AF with mechanical or native valve disease; INR monitoring should be facilitated through community health services and remote INR testing. DOACs are appropriate for non-valvular AF where accessible.

Referral Pathways

Establish early referral pathways to cardiology for arrhythmia assessment, particularly for young Aboriginal and Torres Strait Islander patients with palpitations and suspected RHD. State and territory RHD control programs (e.g., NT RHD Control Program, END RHD CRC) provide specialist support, echo screening, and chronic disease coordination. RFDS and visiting specialist services are critical in remote areas.

📚 References

1. Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. Eur Heart J. 2020;41(5):655–720. doi:10.1093/eurheartj/ehz467
2. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. Eur Heart J. 2021;42(5):373–498. doi:10.1093/eurheartj/ehaa612
3. Page RL, O'Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure. Circulation. 2016;134(6):e32–e69. doi:10.1161/CIR.0000000000000426
4. February TD, Group NHFACSW. Diagnosis and management of atrial fibrillation: National Heart Foundation of Australia. Heart Lung Circ. 2024;33(4):e1–e63.
5. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol. 2014;64(21):e1–e76. doi:10.1016/j.jacc.2014.03.022
6. Priori SG, Blomström-Lundqvist C, Mazzanti A, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2015;36(41):2793–2867. doi:10.1093/eurheartj/ehv316
7. AIHW. Atrial fibrillation in Australia. Cat. No. CDK 14. Canberra: Australian Institute of Health and Welfare; 2022.
8. RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd ed). Darwin: Menzies School of Health Research; 2020.
9. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo (CAST). N Engl J Med. 1991;324(12):781–788. doi:10.1056/NEJM199103213241201
10. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult advanced cardiovascular life support — 2015 AHA Guidelines Update for CPR and ECC. Circulation. 2015;132(18 Suppl 2):S444–S464. doi:10.1161/CIR.0000000000000261
11. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand. Reducing risk in heart disease: guidelines for preventing cardiovascular events. Heart Lung Circ. 2012;21(1):51–60.
12. Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report. Chest. 2018;154(5):1121–1201. doi:10.1016/j.chest.2018.07.040
13. Chen LY, Chung MK, Allen LA, et al. Atrial fibrillation burden: moving beyond atrial fibrillation as a binary entity. Heart Rhythm. 2018;15(10):e31–e40. doi:10.1016/j.hrthm.2018.02.037
14. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Circulation. 2018;138(13):e272–e391. doi:10.1161/CIR.0000000000000549

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).